Electronic Medical Records: Their Time Has Not Yet Come

In 2009, the U.S. Congress passed the American Recovery and Reinvestment Act (ARRA), which provided nearly $26 billion as incentives toward transforming medical records from paper-based to electronic. For those who make the conversion early and fulfill a level of computer utilization termed "meaningful use," there will be monetary bonuses. For those who do not adopt electronic medical records (EMRs) by 2015, there will be reductions of 1 to 5 percent on Medicaid and Medicare payments. The result of this carrot-and-stick approach is that essentially all health care providers are making the uncomfortable transition in their offices from paper to computer.

The reason the government is encouraging this change is based on studies showing that electronic records are more secure, that preventive measures could be better implemented electronically, and that health records could be shared across providers, thus avoiding duplication of testing. If these assumptions were true, medical quality could be improved while costs would decrease.

Unfortunately, as Groopman and Hartzband pointed out in the Wall Street Journal, the studies that show those improvements were conducted by those very companies that would profit most if EMRs were adapted as a national standard. A simple review of the reality of EMRs shows a much less optimistic view.

There are presently hundreds of EMRs from which health care providers must choose, all of which fulfill the requirements for the meaningful use incentive bonuses and all of which are expensive to implement. These systems are independent, though, and do not communicate with each other. The EMR in our office, for example, which was purchased from one of the largest EMR companies in the nation, will allow me to obtain lab and X-ray results that I order at our local hospital. It will not let me obtain medical records from other doctors' offices or from other hospitals. It will not even allow me to view test results at our local hospital that are ordered by other physicians! Medical offices still must rely on phone calls, the fax machine and other systems for that information. The idea of a nationwide electronic data base for each person that could be accessed at every patient encounter remains a broken promise.

Starting an EMR involves a significant disruption for a medical practice as demographic information and patient data are entered for each of the 2,000 to 3,000 patients cared for in a typical primary care office. This process involves physician and staff time, lasts months, and decreases office productivity by 30 percent. Even when EMRs are fully implemented, office efficiency is still decreased as data are entered at every patient encounter, lengthening the amount of time needed for each office visit. The most enthusiastic proponents of EMRs acknowledge that two or three fewer patients can be seen each day when electronic records are used compared to paper records; but those proponents are quick to add that more money can be made since each visit can be "upcoded" and more can be charged to insurers. Doctors code each visit based on the complexity of the encounter. The computer is able automatically to include old medical information in each patient visit and provide prompters to the health professional thus allowing him artificially to increase the complexity. Higher complexity receives higher reimbursement.

So EMRs are expensive to buy, time-consuming to implement and decrease office efficiency, but they allow the doctor to charge more for the same services. They produce very complete records but those records cannot be shared between doctor's offices. Greenhalgh and his colleagues reviewed 500 articles on EMRs. They determined that electronic records were more efficient for audits and billing but less efficient for primary clinical work. They also concluded that smaller, paper-based medical systems offered greater flexibility and efficiency than larger electronic systems. Whether electronic records were more or less secure than paper records could not be determined. The theoretical benefits of an electronic record are not matched by its actual performance-a performance that increases costs but detracts from clinical efficiencies and does nothing to improve patient outcomes. Although the adoption of EMRs is one of the few health care measure to enjoy bipartisan support, the technology is not good enough to warrant that enthusiasm. In health care, the lawmakers have yet to learn that new is frequently not better and change is rarely improvement.